Eli's Rehab Report

Pain management injections such as nerve blocks, trigger point and facet joint are being performed with growing frequency and, as a result, coders need to familiarize themselves with the different types available. If you can read the physiatrists notes to find clues on how to code each procedure, you will have a better chance at reimbursement. The following tips on billing for these can help cut down on returning the chart for more information.

Trigger Point Injections

The most commonly performed pain management injection (trigger point) billing is usually straightforward because there are no site-specific codes for their use they are coded using CPT 20550 (injection, tendon sheath, ligament, trigger points or ganglion cyst). However, some coders who receive a chart note indicating that a pain management injection was performed might confuse it with a nerve block. One Connecticut subscriber reports that the physiatrist sometimes writes nerve block in his notes, and when she reports that code, he asks, Why didnt you use the trigger point code?

If the injection is into the muscle, tendon, fascia, or ligaments, then its most likely a trigger point injection, says Gregory Mulford, MD, FAAPMR, FAAEM, chairman of the department of rehabilitation medicine at Morristown Memorial Hospital in New Jersey, and advisor to the AMA CPT Advisory Committee for the American Academy of Physical Medicine and Rehabilitation.

These are coded by the number of muscle groups injected, not the number of injections. For instance, if the physiatrist administers three injections into the trapezius muscle, only one unit of 20550 can be billed. However, three into the trapezius muscle and two more into the supraspinal muscle would count as two, and would be billed 20550, 20550-59 (distinct procedural service).

Note: Some carriers request that modifier -51 (multiple procedures) be appended instead of -59. This varies by carrier and should be confirmed before billing.

Most payers will reimburse for between five and eight trigger point injection sites per visit, and even those will be scrutinized by Medicare, so be sure to only bill when you have confirmed that more than one site was injected.

Nerve Blocks

It is less common to bill for nerve blocks, and these are often miscoded using 20550. However, seasoned coders may recognize the difference if an unusual number of injections take place. While trigger point injections are billed once per site, despite the number administered, nerve blocks are usually billed all along the nerve, and each injection can be billed separately, says Kimberly A. Stevens, CPC, RMC, president of Medical Billing Solutions Inc. of Edwardsville, Ill., which specializes in billing for pain management. If I saw a doctors note indicating that he performed three injections on a cervical sympathetic nerve, I would know not to bill a trigger point injection. At the very least, I would ask the physiatrist to confirm what was performed.

Another indicator, Mulford says, is the fact that fluoroscopy is normally used with facet joint nerve blocks and epidural injections (64470-64484), and sometimes with the remaining nerve block codes, to ensure optimal placement of the needle. When you see that fluoroscopy has been performed, be aware that something more comprehensive than a trigger point injection was given.

Note: Fluoroscopy can be billed separately for the nerve block codes using 76005.

Because the nerve block category in CPT contains nearly two pages of codes (64400-64530), it can be easy to confuse them. The first step is to determine where the injection took place.

The first set of codes relates to the somatic nerves, which are grouped as 64400-64450, and can be billed by the number of units performed. For instance, if two injections are performed on an axillary nerve, you would code 64417 x 2 units.

The second group of nerve block codes (64470-64484) represents facet joint and epidural injections, which are used for the spine, and contain add-on codes for each additional level performed. This means that these codes cannot be billed according to the number of units injected. For instance, if the physiatrist performs facet joint injections to two levels of the lumbar spine, he or she would bill using one unit of 64475 and one unit of 64476, which is the add-on code for each additional level. If the physiatrist performed facet joint injections to three levels of the cervical spine, he or she would bill one unit of 64470 and two units of 64472.

The final group of nerve block codes is for the sympathetic nerves, which should be billed according to the number of units; there are no add-on codes for these injections. For example, the physiatrist performs four stellate ganglion injections on a patient with pain (729.5) in her arm. Four units of 64510 should be billed. No modifiers need to be added to the claim. It should read: 64510 x 4.

Check If Diagnoses Are Payable Ahead of Time

Even after correct coding is mastered, some claims may still be denied because they lack medical necessity. If an insurer says that a procedure doesnt require preauthorization, its still a good idea to look up the review policy or call the automated line to ensure which ICD-9 codes are acceptable for the procedure youre performing, says Patricia Ryan, CMIS, billing coordinator at Rehab Medicine Associates, a PM&R practice in Hartford, Conn. Specifically with trigger point injections, denials are common, and sometimes the claim will only be off by one digit. For instance, they may pay for low back pain (724.2) but not back pain (724.5).

Diagnoses commonly covered for trigger point injections are carpal tunnel syndrome (354.0), lateral epicondylitis (726.32) and enthesopathy of the knee (726.60).

Ask The Physiatrist

If there is any doubt about which injection you are coding, ask the physiatrist. It can sometimes be difficult to tell which is most appropriate, Mulford says.

Redesigning your practices superbills can help, Ryan says. On our preprinted form, the physiatrist can circle that he has performed a trigger point injection, and there is a space where he can write how many, and on what parts of the body. This type of form can help practices that perform several types of these injections.